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Virtual IraqVirtual Iraq: Virtual Reality Exposure Therapy Virtual Reality Exposure Therapy for OIF/OEF PTSDfor OIF/OEF PTSD
Full Spectrum VR Exposure Full Spectrum VR Exposure Therapy for Iraq War PTSDTherapy for Iraq War PTSD
Skip Rizzo, Ph.D.University of Southern California Director,
VRPSYCH Lab Institute for Creative Technologies, Dept.
of Psychiatry & School of Gerontology
Full Spectrum VR Exposure Full Spectrum VR Exposure Therapy for Iraq War PTSDTherapy for Iraq War PTSD
USC-Institute for Creative Technologies, Emory University, Weill Medical College at Cornell, NMCSD, Virtually Better, Inc., WRAMC, MAMC-Ft. Lewis
Skip Rizzo, Skip Rizzo, Barbara Rothbaum, JoAnn Difede, Barbara Rothbaum, JoAnn Difede, Greg Reger, Josh Greg Reger, Josh SpitalnickSpitalnick,, Ken Ken GraapGraap, , CPT. CPT. Rob Rob McLayMcLay, CDR. Scott Johnston, Jeff , CDR. Scott Johnston, Jeff PynePyne, Karen , Karen PerlmanPerlman, Robert Deal, , Robert Deal, Jarrell Jarrell
Pair, Pair, Tom Parsons, COL. Mike Roy, Tom Parsons, COL. Mike Roy, COL. Greg COL. Greg GahmGahm & CDR. Russell Shilling& CDR. Russell Shilling
Virtual IraqVirtual Iraq: Virtual Reality Exposure Therapy Virtual Reality Exposure Therapy for OIF/OEF PTSDfor OIF/OEF PTSD
Talk Outline:
Introduction to Clinical VR Exposure Therapy Virtual Iraq Exposure Therapy for
Post Traumatic Stress Disorder Dr. Thomas Parsons on Cognitive
Testing with Virtual Iraq
Virtual IraqVirtual Iraq: Virtual Reality Exposure Therapy for OIF/OEF PTSD
Skip Rizzo, Thomas Parsons, Belinda Lange, Sheryl Flynn, Patrick Kenny, Luke Yeh, John Brennan & Brad Newman
Anxiety Disorders/PTSD
Motor Function Assessment & Rehabilitation
(TBI, Stroke, SCI, Prosthetics)
Pain Distraction & Discomfort
Reduction
University of Southern CaliforniaInstitute for Creative Institute for Creative TechologiesTechologies
VRPSYCH Lab Project AreasVRPSYCH Lab Project Areas
Cognitive Assessment and Rehabilitation
(ADHD, TBI, Alzheimer’s, Stroke)
Funded byFunded by
Vir t ual Ir aq Vir t ual Ir aq for PTSD Treatmentfor PTSD Treatment
VR Classroom forVR Classroom forADHD AssessmentADHD Assessment
VR/Games to Motivate Motor RehabilitationVR/Games to Motivate Motor Rehabilitation
VR Games Pain Distraction ProjectVR Games Pain Distraction Project (Lange, Rizzo & Gold)
Skip Rizzo, Thomas Parsons, Belinda Lange, Sheryl Flynn, Patrick Kenny, Luke Yeh, John Brennan & Brad Newman
Anxiety Disorders/PTSD
Motor Function Assessment & Rehabilitation
Virtual Patient Clinical Training
VRPSYCH Lab Project AreasVRPSYCH Lab Project Areas
Cognitive Assessment and Rehabilitation
VR Games to Motivate Motor Rehabil itat ionVR Games to Motivate Motor Rehabil itat ion
VR VR Class forClass for ADHDADHD AssessmentAssessment
VR Games Pain Distraction ProjectVR Games Pain Distraction Project (Lange, Rizzo & Gold)
VR Pain Distraction and VR Pain Distraction and Discomfort ReductionDiscomfort Reduction
And one more…
VR Games Pain Distraction ProjectVR Games Pain Distraction Project (Lange, Rizzo & Gold)
Virtual Reality integrates Virtual Reality integrates realtimerealtimecomputer processing, body tracking computer processing, body tracking and and
interface devices, sensory displays to interface devices, sensory displays to immerse a participant in a computer immerse a participant in a computer
generated simulated environment. Within generated simulated environment. Within such controllable, dynamic and interactive such controllable, dynamic and interactive
3D stimulus environments, behavioral 3D stimulus environments, behavioral action can be recorded and measured.action can be recorded and measured.
Virtual Reality DefinitionVirtual Reality Definition
Virtual Reality DefinitionVirtual Reality Definition
“…a way for humans to interact with computers and extremely complex data in a more naturalistic fashion.”
The Evolution of the Tool-Using Animal
=
1st Link Aviation Simulator (1929) Virtual Reality (2009)
Virtual Reality as a Simulation Technology
=
1st Link Aviation Simulator (1929) Virtual Reality (2009)
To Test and Train Piloting Ability
To Assess and Rehabilitate Cognitive, Psychological, &
Motor Functioning
=
1st Link Aviation Simulator (1929) Virtual Reality (2009)
To Test and Train Piloting Ability
To Assess and Rehabilitate Cognitive, Psychological, &
Motor Functioning
And note that a Meta Analysis of Aviation Simulation Research indicates a “Transfer Effectiveness Ratio” of .48 (Johnston, 1995).
Types of Virtual Types of Virtual RealitiesRealities
Gaming Applications
Flatscreen VR
Panoram Tech 3-Screen Desktop
Multiple Flatscreens
Veridian SystemInterface for Retraining Driving Skills following Spinal Cord Injury (Collab w/Kessler Rehab.)
D esigned b y: Rizz o, D esigned b y: Rizz o, Kl imchuk Kl imchuk & & Mit ur aMit ur a
Auto-stereoscopic 3-D Display(courtesy of Dimension Technologies Co.)
18.1” LCD display,Resolution: 12801024
Mini-Workbench
CAVE 3-D large volume display (Fakespace Co.)
Auto-stereoscopic 3-D Display(courtesy of Dimension Technologies Co.)
18.1” LCD display,Resolution: 12801024
Mini-Workbench
CAVE 3-D large volume display (Fakespace Co.)
Auto-stereoscopic 3-D Display(courtesy of Dimension Technologies Co.)
18.1” LCD display,Resolution: 12801024
Sharp Autostereoscopic Display with Stroke Patient
Mini-Workbench
CAVE 3-D large volume display (Fakespace Co.)
Co nsu mer St er eo Capabl e Scr eensConsu mer St er eo Capabl e Scr eens
$2,000$2,000
Head Mounted Head Mounted Displays (HMD)Displays (HMD)
“Virtual reality arrives at a moment when computer technology in general is moving from
automating the paradigms of the past to creating new ones for the future” (Myron Krueger, 1993)
EXPOSUREEXPOSURETherapy!Therapy!
VR Exposure for AnxietyAnxiety Disorders• Heights • Flying• Driving• Spiders/snakes• Public Speaking• Claustrophobia• Generalized Social Phobia• Panic Disorder with
Agoraphobia• Post Traumatic Stress
Disorder
Riva Hoffman
North
Hodges/Rothbaum
Hodges/Rothbaum
Emmelkamp
KIM
Previ
Midtown Madness
The aim of exposure is to help the patient to confront the feared stimulus in order to correct the dysfunctional associations that have been established between the stimulus and perceived threat (e.g, it is dangerous, I can’t cope).
VR Exposure for Anxiety DisordersVR Exposure for Anxiety Disorders
Exposure to feared stimulus repeatedly and for prolonged period leads to habituation and extinction
Based on learning/conditioning principles Reliable findings with animals and simple
phobic disorders Prolonged Imaginal Exposure
Exposure Therapy PrinciplesExposure Therapy Principles
Fear of HeightsFear of Heights
• Lamson (1995)• 9 participants
• Hodges, Rothbaum, & North (1995)• 17 undergraduate students
• Bullinger (1997)• VR vs. In vivo
• Huang (1998)• VR vs. In vivo
• Emmelkamp, Krijin, Schuemie (1999)• VR vs. In vivo
• Kim, Jang, & Choi (1999)• Wiederhold (2000)• Scheumie (2002)
Fear of HeightsFear of Heights……Research StudiesResearch Studies
• Lamson (1995)• 9 participants
• Hodges, Rothbaum, & North (1995)• 17 undergraduate students
• Bullinger (1997)• VR vs. In vivo
• Huang (1998)• VR vs. In vivo
• Emmelkamp, Krijin, Schuemie (1999)• VR vs. In vivo
• Kim, Jang, & Choi (1999)• Wiederhold (2000)• Scheumie (2002)
Fear of HeightsFear of Heights……Success Stories!Success Stories!
Fear of HeightsFear of Heights……Success Stories!Success Stories!
Hodges, Rothbaum et al., 1994
Fear of Heights(Rothbaum and Hodges)
Modeled from the Glass Elevator in the Atlanta Marriott
Fear of Heights Exposure TherapyUsing UnrealUnreal Tournament Game Engine
(Bouchard et al., 2003)
VR Claustrophobia Application(Botella et al., 1997)
Journal of Anxiety Disorders
Journal of Behavior Therapy and Experimental
Psychiatry
VR Anxiety Disorders Meta-Analysis
2008
In: Parsons & Rizzo (2008) Journal of Behavior Therapy & Experimental Psychiatry
VR Anxiety Disorders Meta-Analysis
VR Exposure for AnxietyAnxiety Disorders• Heights • Flying• Driving• Spiders/snakes• Public Speaking• Claustrophobia• Generalized Social Phobia• Panic Disorder with
Agoraphobia
•• Post Traumatic StressPost Traumatic StressDisorderDisorder
Funded byFunded by
Full SpectrumFull Spectrum
VR VR
Exposure Therapy for
Exposure Therapy for
OIFOIF//OEFOEF PTSDPTSD
Post Traumatic Stress Disorder (DSM-4-TR) is caused by exposure to traumatic events that are outside the range of usual human experiences such as military combat, violent personal assault, being kidnapped or taken hostage, terrorist attack, torture, incarceration as a prisoner of war, natural or man-made disasters, automobile accidents, or being diagnosed with a life-threatening illness.
The disorder also appears to be more severe and longer lasting when the event is caused by human means and design (bombings, shootings, combat, etc.).
Post Traumatic Stress DisorderPost Traumatic Stress Disorder
Re-experiencing (nightmares/flashbacks/intrusions)
Avoidance Emotional Numbing Hyper-arousal
General symptoms
Post Traumatic Stress DisorderPost Traumatic Stress Disorder
“…The percentage of study subjects whose responses met the screening criteria for major depression, generalized anxiety, or PTSD was significantly higher after duty in Iraq (15.6 to 17.1 percent) than after duty in Afghanistan (11.2 percent) or before deployment to Iraq (9.3 percent)” (Hoge et al., 2004)
Rothbaum BO et al. J Traumatic Stress. 1992;5(3):464
30
25
15
10
5
20
2 3 4 5 6 7 8 9 10 11 121
Non-PTSD
PTSD
0
Assessment over Time
Severity of PTSD SymptomsSeverity of PTSD Symptoms
CA
PS S
core
-Sy
mpt
om S
ever
ity
The aim of exposure is to help the patient to confront the feared stimulus in order to correct the dysfunctional associations that have been established between the stimulus and perceived threat (e.g, it is dangerous, I can’t cope).
Exposure for Anxiety DisordersExposure for Anxiety Disorders
Exposure Therapy PrinciplesExposure Therapy Principles
Exposure to feared stimulus repeatedly and for prolonged period leads to habituation and extinction
Based on learning/conditioning principles Reliable findings with animals and simple
phobic disorders One of the “Evidence-Based” PTSD
approaches endorsed by DOD/VA/NAS and ISTSS treatment guidelines
Prolonged Therapeutic Exposure
Exposure Therapy PrinciplesExposure Therapy Principles
Exposure to feared stimulus repeatedly and for prolonged period leads to habituation and extinction
Based on learning/conditioning principles Reliable findings with animals and simple
phobic disorders Prolonged Therapeutic Exposure One of the “Evidence-Based” PTSD
approaches endorsed by DOD/VA/NAS and ISTSS treatment guidelines
The committee reviewed 53 studies of pharmaceuticals and 37 studies of psychotherapies used in PTSD treatment and concluded that because of shortcomings in many of the studies, there is not enough reliable evidence to draw conclusions about the effectiveness of most
treatments. There are sufficient data to conclude that There are sufficient data to conclude that exposure therapiesexposure therapies ---- such as exposing individuals such as exposing individuals to a real or surrogate threat in a safe environment to a real or surrogate threat in a safe environment to help them overcome their fears to help them overcome their fears ---- are effective in are effective in treating people with PTSD.treating people with PTSD.
Of those diagnosed with Posttraumatic Of those diagnosed with Posttraumatic Stress Reaction at 30 Days PostStress Reaction at 30 Days Post
0102030405060708090
100
Treatment Conditions
Exposure Therapy
Supportive Counseling
No Treatment
Comparison between Exposure TherapyExposure Therapy,
Supportive CounselingSupportive Counselingand No TreatmentNo Treatment on
PTSD incidence
(Bryant et al., 1999; 2005)
% w
ith
PT
SD
at
6 M
on
ths
Of those diagnosed with Posttraumatic Of those diagnosed with Posttraumatic Stress Reaction at 30 Days PostStress Reaction at 30 Days Post
0102030405060708090
100
Treatment Conditions
Exposure Therapy
Supportive Counseling
No Treatment
% w
ith
PT
SD
at
6 M
on
ths
Comparison between Exposure Therapy,
Supportive Counseling and No TreatmentNo Treatment on
PTSD incidence
(Bryant et al., 1999; 2005)
Of those diagnosed with Posttraumatic Of those diagnosed with Posttraumatic Stress Reaction at 30 Days PostStress Reaction at 30 Days Post
0102030405060708090
100
Treatment Conditions
Exposure Therapy
Supportive Counseling
No Treatment
% w
ith
PT
SD
at
6 M
on
ths
Comparison between Exposure Therapy,
Supportive CounselingSupportive Counselingand No Treatment on
PTSD incidence
(Bryant et al., 1999; 2005)
Of those diagnosed with Posttraumatic Of those diagnosed with Posttraumatic Stress Reaction at 30 Days PostStress Reaction at 30 Days Post
0102030405060708090
100
Treatment Conditions
Exposure Therapy
Supportive Counseling
No Treatment
% w
ith
PT
SD
at
6 M
on
ths
Comparison between Exposure TherapyExposure Therapy,
Supportive Counseling and No Treatment on
PTSD incidence
(Bryant et al., 1999; 2005)
Many patients are unwilling or unable to effectively visualize the traumatic event. In fact, avoidance of reminders of the trauma is inherent in PTSD, and is one of the defining symptoms of the disorder. Research on this aspect of PTSD treatment suggests that the inability to emotionally engage (in imagination) is a predictor for negative treatment outcomes (Jaycox, Foa, & Morral, 1998).
“…some patients refuse to engage in the treatment, and others, though they express willingness, are unable to engage
their emotions or senses.” (Difede & Hoffman, 2002).
Post Traumatic Stress DisorderPost Traumatic Stress Disorder Problems with Imaginal Exposure
VR PTSD ExamplesVR PTSD Examples
Virtual Vietnam – Emory University
World Trade Center – Weill Cornell Medical Center/U of Wash
Terrorist Bus Bombing - U. of Haifa/U of Wash
Motor Vehicle Accidents – Univ. of Buffalo
Emma’s World - Universitat de València (Spain)
Virtual Angola – U. of Lusófona de Humanidades e Tecnologias, Lisbon
Virtual Iraq – USC Institute for Creative Technologies
Virtual VietnamVirtual VietnamHodges, Rothbaum, Graap, Pair et al.
In 1997, researchers at Georgia Tech released the first version of
the Virtual Vietnam VR scenario for use as a graduated exposure
therapy treatment for PTSD with Vietnam veterans.
This occurred over 20 years following the end of the Vietnam War.
• Ready et al. (1998) – Atlanta VA early pilot study• 34% decrease in clinician-rated PTSD symptoms• 45% decrease in self-rated PTSD symptoms
• Rothbaum et al. (1999) - case study + at 6-month FU• Rothbaum et al. (2001) – open clinical trial (n=16)
Virtual Vietnam PTSD Studies
““Virtually HealedVirtually Healed”” ……a Discovery Health a Discovery Health Channel Documentary PTSD SegmentChannel Documentary PTSD Segment
4:1
VR PTSD Example
World Trade Center - Weill Cornell Medical Center/HIT-Lab, Univ. of Washington
Virtual Reality Exposure Therapy for Treatment Virtual Reality Exposure Therapy for Treatment of Acute World Trade Center PTSD: A case studyof Acute World Trade Center PTSD: A case study
JoAnn DifedeJoAnn Difede, Ph.D., Ph.D.CornellCornell--Presbyterian Hospital in ManhattanPresbyterian Hospital in Manhattan
Hunter Hoffman, Ph.D.Hunter Hoffman, Ph.D.U. of Washington U. of Washington HITlabHITlab in Seattlein Seattle
Thanks to Pfizer PharmaceuticalsThe Paul Allen Foundation for Medical ResearchNational Institutes of HealthDell ComputersAnd www.3dcafe.com for a model of Manhattan.
(Difede et al., 2002)
Table 1 Self-Report Scores of PTSD and Depression
Depression (BDI )
PTSD (PDS)
Total Score
Reexperience Symptoms
Avoidance Symptoms
Arousal Symptoms
Baseline 37.00 37.00 9.00 16.00 12.00 VR Session 1
(week 5) 30.00 40.00 13.00 14.00 13.00
Completion of Treatment (week 14)
5.00 4.00 1.00 0.00 3.00
Note that Re-experiencing Symptoms + Avoidance Symptoms + Arousal Symptoms = PTSD Total Score.
Virtual WTC PTSD Studies
Difede, J., Cukor, J., Patt, I., Goisan, C. & Hoffman, H. (2006). The Application of Virtual Reality to the Treatment of PTSD Following the WTC Attack. Journal of Clinical Psychiatry, 68, 1639-1647 (2007)
n = 17 Active Treatment = Statistically and Clinically
meaningful reduction in CAPS scores Five of nine successful patients showed no gain
from previous “imaginal” exposure therapy
Waiting List Control Study Results:
Terrorist Bus Bombing - U. of Haifa/U of Wash. HIT Lab
VR PTSD Example
Terrorist Bus Bombing - U. of Haifa/U of Wash. HIT Lab
VR PTSD Example
Motor Vehicle Accidents – Univ. of Buffalo
VR PTSD Example
Motor Vehicle Accidents – Univ. of BuffaloJ. Gayle Beck – Randomized Clinical Trial in progress. Four observations at this point:
VR producing better outcomes than control
Motion platform enhances “engagement”
VR + adherence to CBT homework = better outcomes
**Therapist Skill in delivering **Therapist Skill in delivering trigger stimuli appears related trigger stimuli appears related to outcomesto outcomes
VR PTSD Example
Virtual Angola
Portugal – From 1961-1974 war on three fronts:
Mozambique
Angola
Guiné
1Universidade Lusófona de Humanidades e Tecnologias, Lisbon, Portugal2Militar Academy, Lisbon, Portugal3Hospital Júlio de Matos, Lisbon, Portugal
Pedro Gamito1, PhDCarlos Ribeiro2, PhDLuiz Gamito3, MDJosé Pacheco3, MScCristina Pablo3
Tomaz Saraiva1
25,000 with Combat Related PTSD
VR PTSD Example
Virtual Angola
Problems with “Flooding” approach in Initial User Test with PTSD patient
VR PTSD Example
MedICLab
Medical ImageComputingLaboratory
EMMAEMMA Project
Engaging Media for Mental health Applications
Christina Botella, Universitat Jaume I, Castellon (Spain)
EMMAEMMA’’S WORLD:S WORLD: An “OPEN VR SYSTEM”
PURPOSEPURPOSE:: In this space the user can remember and relive past experiences, rest, recover, and commit to moving forward.
Botella et al., 2006
Multiple Rear-Projected Display
Wireless Joystick Navigation
EMMAEMMA’’S WORLD:S WORLD: An “OPEN VR SYSTEM”EMMAEMMA’’S WORLD:S WORLD:
Types of Elements:Types of Elements:3D objects3D objectsVideosVideosImagesImagesSoundsSoundsMusicMusicColoursColours
A ClinicianA Clinician’’s Interface to s Interface to control Elements that are control Elements that are integrated into EMMA:integrated into EMMA:
Elements can be copied to the living book from the database screen.
Different chapters can be added. Purpose: to help the user to re-live the
past as it happens with family photographs and home videos.
The Living Book:The Living Book:
EMMAEMMA’’S WORLD:S WORLD:
EMMAEMMA’’S WORLD:S WORLD: Case Study
33-year-old woman PTSD developed from an episode of physical
aggression by her partner She was pregnant. After the agression she decided to abort
OUTCOME MEASURES
0
2
4
6
8
10
FEAR AVOIDANCE
BEHAVIOUR 1: having sexual relations with men
PRE
POST
0
2
4
6
8
10
FEAR AVOIDANCE
BEHAVIOUR 2: relating with men in general (friends, known people…)
PRE
POST
0
2
4
6
8
10
FEAR AVOIDANCE
BEHAVIOUR 3: seeing children
PRE
POST
0
2
4
6
8
10
FEAR AVOIDANCE
BEHAVIOUR 4: going out of home
PRE
POST
Fear/avoidance of target-behaviours before and after therapy
0
10
20
30
40
50
CRITERION C
PRE POST
Avoidance
0
10
20
30
CRITERION B
PRE
POST
Re-experimentation
0
10
20
30
40
CRITERION D
PRE POST
Hyperarousal
DAVIDSON Trauma Scale scores
Hypothetical use of EMMAHypothetical use of EMMA’’s world fors world forIraq War PTSDIraq War PTSD
Virtual Vietnam – Emory University
World Trade Center – Weill Cornell Medical Center/U of Wash
Terrorist Bus Bombing - U. of Haifa/U of Wash
Motor Vehicle Accidents – Univ. of Buffalo
Emma’s World - Universitat de València (Spain)
Virtual Angola – U. of Lusófona de Humanidades e Tecnologias, Lisbon
Virtual Iraq – USC Institute for Creative Technologies
VR PTSD ExamplesVR PTSD Examples
Funded byFunded by
Virtual IraqVirtual Iraqand nowand now Virtual Virtual AfghanistaAfghanista
X-Box Game Conversion for Iraq War PTSD clients!
Full Spectrum Warrior
X-Box Game Conversion for Iraq War PTSD clients!
Full Spectrum Warrior
Game Conversion for Iraq War PTSD clients!
Full Spectrum Warrior
Multiple Scenario Settings Selectable User Perspective Options Create Library of “Trigger” Stimuli Integrate Scent, Vibration and Phys. Props
Create a Highly Usable Create a Highly Usable ““Wizard of OZWizard of OZ””Clinician InterfaceClinician Interface
Integrate Physiological Recording into Clinician Interface
Major Goal: Customize Graduated Customize Graduated Exposure based on Client NeedsExposure based on Client Needs
Global PTSD RequirementsGlobal PTSD Requirements
Virtual IraqVirtual Iraq
Multiple Scenario Settings Selectable User Perspective
Options Library of “Trigger” Stimuli Integrate Scent, Vibration and
Phys. Props
Highly Usable Highly Usable ““Wizard of OZWizard of OZ””Clinician InterfaceClinician Interface
Integrate Physiological Recording into Clinician Interface
Major Goal: Customize Graduated Customize Graduated Exposure based on Client NeedsExposure based on Client Needs
Global PTSD RequirementsGlobal PTSD Requirements
Virtual IraqVirtual Iraq
Virtual IraqVirtual IraqEarly Prototype of Virtual CityEarly Prototype of Virtual City
Virtual IraqVirtual IraqTime of Day and Weather ControlsTime of Day and Weather Controls
Night VisionNight Vision
Virtual IraqVirtual IraqCity Building InteriorsCity Building Interiors
Virtual IraqVirtual IraqDesert Highway and VillageDesert Highway and Village
Desert Highway CheckpointDesert Highway Checkpoint
Virtual IraqVirtual Iraq
HumveeHumvee Interior Interior –– Safe Safe ViewView
Virtual IraqVirtual Iraq
Humvee Humvee TurretTurret ViewView
Virtual IraqVirtual Iraq
Humvee Humvee Interior Interior ActionAction ViewView
Virtual IraqVirtual Iraq
Humvee Humvee Interior Interior ActionAction ViewView
Virtual IraqVirtual Iraq
Too Creepy for Too Creepy for Therapy??Therapy??
Humvee Humvee Interior Interior ActionAction ViewView
Virtual IraqVirtual Iraq
Virtual IraqVirtual IraqAfghanistanAfghanistan--like Content now being addedlike Content now being added
Virtual IraqVirtual IraqAfghanistanAfghanistan--like Content now being addedlike Content now being added
Caveat: We need to guard against the perception that VR Tools are designed to eliminate the need for the Well Trained Clinician
Challenges
So, Tell me about your
mother?
Scenario Settings Location, Time of Day,
Weather, etc.
User Perspective Alone, Patrol, HUMVEE,
Helicopter, etc.
Real-Time PsychophysiologicalDisplay
TRIGGER Stimuli
“Wizard of OZ” Clinician Interface
Global FSW PTSD Requirements
The “Wizard of Oz” type clinical interface is a key element in the application, as it needs to provide a clinician with a usable tool for placing the user in VE locations that resemble the setting and context in which the traumatic events initially occurred.
As important, the clinical interface must also allow the clinician to further customize the therapy experience to the patient’s individual needs of via the systematic real-time delivery and control of “trigger” stimuli in the environment.
Visual Display of client’s FOV and psychophysiological status This is essential for fostering the anxiety modulation needed for
therapeutic habituation.
Create a Highly Usable “Wizard of OZ”Clinician Interface
Wireless Tablet Option
“Wizard of OZ” Clinician Interface
eMAGINEeMAGINE, Inc., Inc.
Low Cost Accessible Display Technology
eMAGINEeMAGINE, Inc., Inc.
Low Cost Accessible Display Technology
$1500
or
High Fidelity Wide FOV (approx. 150 degrees)??$
(Bolas & Rizzo, 2008)
EnviroScentEnviroScent SystemSystem
Gunpowder Cordite Body Odor Garbage Burning Rubber Diesel Fuel Iraqi Spices
MultisensoryMultisensory StimuliStimuliScent and Vibration
Night Night Vision Vision HMD HMD RigRig
Courtesy of Quantum Courtesy of Quantum 3D3D
Base Base ShakerShakerPlatformPlatform
Integrate Scent and VibrationNatural Navigational ControlNatural Navigational Control
Portable Psychophysiology ToolPortable Psychophysiology Tool
A nonA non--intrusive Virtual Emotion Sensor that is worn much intrusive Virtual Emotion Sensor that is worn much like a pair of glasses. The headset acquires several like a pair of glasses. The headset acquires several
biometric signalsbiometric signals such as EEG, Heartrate, blood oxygen, and motion and processes them in real timeand processes them in real time. The module
is connected to a computer through a wireless link.
User Centered Trials in IRAQIRAQ and Ft Lewis (Equipment funded by TATRC)
Current Research ActivitiesCurrent Research Activities
TATRC-Funded User Centered Design Protocol in
IRAQ
CPT. Greg Reger Ph.D.
98th Med Det.
Combat stress control team
Tallil ab lsa adder iraq
User-Centered Feedback from Iraq and MAMC-Ft. Lewis
HMD comfort = 7.2/10 Tracking update = 7.4/10 Graphic realism = 6.7/10 Audio realism =7.2/10 Navigation = 6.2/10 Side effects = 3/27; 1DC Much useful qualitative feedback on
architecture, olfactory cues, human content, landscape, etc.
In Press: Telemedicine and E-Health
n=93n=93
Reger, Gahm, Rizzo, Swanson & Duma Soldier Evaluation of the Virtual Reality Iraq
User Centered Trials in IRAQIRAQ and Ft Lewis (Equipment funded by TATRC)
Clinical Trials ongoing at the Ft. Lewis, San Diego Naval Med. Center, Camp Pendleton, Cornell Weill, Walter Reed AMC & Emory Univ. and 12 other military and VA Centers
Current Research ActivitiesCurrent Research Activities
User Centered Trials in IRAQIRAQ and Ft Lewis (Equipment funded by TATRC)
Clinical Trials ongoing at the Ft. Lewis, San Diego Naval Med. Center, Camp Pendleton, Cornell Weill, Walter Reed AMC & Emory Univ. and 12 other military and VA Centers
Clinical Version 1.6 to be Released Oct 2008
Current Research ActivitiesCurrent Research Activities
Open Clinical Trial ProtocolNaval Medical Center San Diego
Session 1 Clinical interview to identify the index trauma, provide psychoeducation on
trauma and PTSD, and instruction on a deep breathing technique for general stress management purposes.
Session 2 Provide instruction on the use of Subjective Units of Distress (SUDS), the
rationale for prolonged exposure (PE), including imaginal exposure and in-vivo exposure. First experience with imaginal exposure of the index trauma and in-vivo hierarchy exposure list was constructed with the first itemassigned as homework.
Session 3 Present rationale for VRET and have the participant experience the VR
environment without recounting the index trauma narrative for approximately 25 minutes with no provocative trigger stimuli introduced. The purpose of not recounting the index trauma was to allow the participant to navigate Virtual Iraq in an exploratory manner and to function as a “bridge session” from imaginal alone to imaginal exposure combined with virtual reality.
Sessions 4-10 Focus on engagement in Virtual Iraq while recounting the trauma narrative
VariableVariable Treatment CompletersTreatment Completersn=20n=20
GenderGender
MaleMale
FemaleFemale19 (95%) 19 (95%)
1 (5.0%)1 (5.0%)
AgeAge 28.1 (28.1 (sdsd=8.4)=8.4)
Marital Status Marital Status
MarriedMarried
DivorcedDivorced
WidowedWidowed
SeparatedSeparated
Never been Never been
14 (70%)14 (70%)
2 (10%)2 (10%)
1 (5%)1 (5%)
1 (5%)1 (5%)
2 (10%)2 (10%)
RankRank
E1E1--E2 2 (10%) E2 2 (10%)
E3E3--E4 E4 9 (45%)9 (45%)
E5E5--E6 E6 6 (30%)6 (30%)
E7E7--E9 E9 3 (15%)3 (15%)
VariableVariable Treatment CompletersTreatment Completersm (m (sdsd))
Years ServiceYears Service 8.4 (7.8)8.4 (7.8)
Months since last Months since last DEPLOYMENTDEPLOYMENT
8.3 (2.5)8.3 (2.5)
DEPLOYMENTS DEPLOYMENTS (# in career)(# in career)
2.6 (2.1)2.6 (2.1)
BranchBranch
ArmyArmy
MarinesMarines2 (10%)2 (10%)
18 (90%)18 (90%)
Demographics
17
22
27
32
37
42
47
52
57
PRE TX POST TX
Pre-TreatmentPost-Treatment
3 Month FU
p < .001(n=20)
16 of 20 No Longer meet DSM criteria for PTSD at Post-TX
PC
L-M
p < .001(n=14)
1 Week Post TX
3 Month Post TXPre-TX
Naval Med Center SD/Camp PendletonNaval Med Center SD/Camp PendletonPTSD Checklist-Military (PCL-M)
PreTreatment, PostTreatment & 3 Month Follow-up
Average # of Sessions < 11Treatment Completers n=20
In Press: Rizzo, Reger, G
ahm,
Difede & Rothbaum, (2008). The
Neurobiology of PTSD, Shiromani,
P., Keane, T. & LeDoux, J. (Eds.)
40
35
25
20
15
30
Assessment over Time
45
50
55
60
65
70
75
80
Pre-Treatm
ent
Post-Tre
atment
Post Tx Follo
w
Up
PCL-
M S
core
-Sy
mpt
om S
ever
ity
Average # of Sessions < 11
16 Successful
Treatment Completers n=20
17 = No 17 = No Symptoms Symptoms EndorsedEndorsed
4 Unsuccessful
Naval Med Center SD/Camp PendletonNaval Med Center SD/Camp PendletonPTSD Checklist-Military (PCL-M)
PreTreatment, PostTreatment & 3 Month Follow-up
40
35
25
20
15
30
PCL-M Assessment over Time
Naval Med Center SD/Camp Pendleton Naval Med Center SD/Camp Pendleton PTSD Checklist-Military (PCL-M)
PreTreatment, PostTreatment & 3 Month Follow-up
4550556065707580
Pre-Treatment
Post-Treatm
ent
Post Tx Follow Up
PCL-
M S
core
-Sy
mpt
om S
ever
ity
Average # of Sessions < 11
16 Successful
Treatment Completers n=20
17 = No 17 = No Symptoms Symptoms EndorsedEndorsed
4 Unsuccessful
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Beck Anxiety PHQ-Depression
Pre-Treatment
Post-Treatment
3 Month FUp < .003
p < .002
In Press: Rizzo, Reger, G
ahm,
Difede & Rothbaum, (2008). The
Neurobiology of PTSD, Shiromani,
P., Keane, T. & LeDoux, J. (Eds.)(n=14)
(n=20)
(n=20)
p < .004
p < .001
(n=14)
Pre-TX1 Week Post TX
3 Month Post TXPre-TX
1 Week Post TX
3 Month Post TX
Naval Med Center SD/Camp PendletonNaval Med Center SD/Camp PendletonBeck Anxiety & PHQ Depression
PreTreatment, PostTreatment & 3 Month Follow-up
Average # of Sessions < 11Treatment Completers n=20
16 of 20 No Longer meet DSM criteria for PTSD at Post-TX
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Beck Anxiety PHQ-Depression
Pre-Treatment
Post-Treatment
3 Month FUp < .003
p < .002
(n=14)
(n=20)
(n=20)
p < .004
p < .001
(n=14) Average # of Sessions < 11Treatment Completers n=20
Naval Med Center SD/Camp Pendleton Naval Med Center SD/Camp Pendleton Beck Anxiety & PHQ Depression
PreTreatment, PostTreatment & 3 Month Follow-up
Pre-TX Pre-TX
Beck Anxiety
1 Week Post TX
PHQ-Depression
3 Month Post TX
1 Week Post TX
3 Month Post TX
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Beck Anxiety PHQ-Depression
Pre-Treatment
Post-Treatment
3 Month FUp < .003
p < .002
(n=14)
(n=20)
(n=20)
p < .004
p < .001
(n=14) Average # of Sessions < 11Treatment Completers n=20
Naval Med Center SD/Camp Pendleton Naval Med Center SD/Camp Pendleton Beck Anxiety & PHQ Depression
PreTreatment, PostTreatment & 3 Month Follow-up
Pre-TX Pre-TX
Beck Anxiety
1 Week Post TX
PHQ-Depression
3 Month Post TX
1 Week Post TX
3 Month Post TX
PTSD Results as of July 2008PTSD Results as of July 2008
Treatment completers successful = 16Treatment completers successful = 16 Treatment completers unsuccessful = 4
Treatment discontinued Treatment discontinued BEFORE FIRST SessionFIRST Session: = 7: = 7 Treatment discontinued BEFORE FIRST VR SessionFIRST VR Session: 6 Treatment discontinued AFTER FIRST VR SessionFIRST VR Session: 7
Naval Med Center Naval Med Center –– San Diego/Camp Pendleton Open Clinical TrialSan Diego/Camp Pendleton Open Clinical Trial
Challenge:Challenge: DropDrop--outs!outs!
How does this compare with Military Mental Healthcare How does this compare with Military Mental Healthcare attrition Rates???attrition Rates???
13/20 = 65 % of dropouts before full VRET therapy begins in session 4
30
20
0
10
Treatment Completer
40
50
60
70
80
90
100
110
PreTreatment
PostTreatm
ent
CA
PS S
core
-Sy
mpt
om S
ever
ity
6 Sessions
Assessment over Time
In Press: Reger e
t al. T
he
Journal
of Clin
ical P
sycholo
gy.
Madigan Army Medical CenterMadigan Army Medical Center--Ft. LewisFt. Lewis(Reger et al)(Reger et al)
PTSD Checklist-Military (PCL-M)PreTreatment & PostTreatment
VRETVRET CBT GroupCBT Group
1. PE non-responders or those specifically seeking VR treatment.
2. 90-minute sessions
3. Sessions were approx weekly
4. Range number of sessions was 5-11 depending on progress.
5. 25 patients received or currently receiving VR Exposure
1. Group for those unwilling to access individual trauma focused therapy (PE, CPT, EMDR)
2. Psychoeducational and skills based CBT class.
3. 11 weekly 90-minute sessions
4. Range number of sessions was 7-14 depending on progress.
Madigan Army Medical CenterMadigan Army Medical Center--Ft. LewisFt. Lewis(Reger et al)(Reger et al)
Non-Random Comparison with Standard of Care
MAMC IRB Protocol #208080; Data preliminary, not for publication
17
22
27
32
37
42
47
52
57
62
VRET Group CBT
Pre-Treatment
Post-Treatment
p <.005 (n=11)
Pre-TX Post TX
Average # of Sessions < 8.3
Madigan Army Medical CenterMadigan Army Medical Center--Ft. LewisFt. Lewis(Reger et al)(Reger et al)
PTSD Checklist-Military (PCL-M)PreTreatment & PostTreatment
VRETVRET: 7 of 11 [63%] No Longer met DSM criteria for PTSD at Post-TX and showed clinically meaningful decrease (>10 pts.) based on Monson et al., 2008
p <.05 (n=7)
Pre-TXPost TX
CBT Group
CBT Group CBT Group : 2 of 7 [28%] No Longer met DSM criteria for PTSD at Post-TX and showed clinically meaningful decrease (>10 pts.) based on Monson et al., 2008
VRET
MAMC IRB Protocol #208080; Data preliminary, not for publication
At Post TX VRET > CBT Group
p <.01 (n=18)
VRETVRET: 7 of 11 [63%] No Longer met DSM criteria for PTSD at Post-TX and showed clinically meaningful decrease (>10 pts.) based on Monson et al., 2008
CBT Group CBT Group : 2 of 7 [28%] No Longer met DSM criteria for PTSD at Post-TX and showed clinically meaningful decrease (>10 pts.) based on Monson et al., 2008
VRET Drop Out = Terminated treatment prior to clinical benefit or 10 sessions (whichever happened first).
CBT Group Drop Out = Completed 5 or fewer group sessions and did not return despite attempted phone contact.
0
20
40
60
80
100
VRET CBT Group Therapy
Perc
ent
42%
72%
8/19 Dropped out 50/69 Dropped out
Madigan Army Medical CenterMadigan Army Medical Center--Ft. LewisFt. Lewis(Reger et al)(Reger et al)
Non-Random Comparison with Standard of Care
MAMC IRB Protocol #208080; Data preliminary, not for publication
Limitations of Effectiveness Study
Comparison of individual and group treatments Groups not likely drawn from the same population:
CBT group represents a treatment resistant group by definition. VRET group includes PE treatment failures.
Lack of random assignment to groups. A number of uncontrolled covariates (e.g., duration of treatment,
medications being used concurrently, etc). Preliminary results: Comparison should only be as a point of reference
MAMC IRB Protocol #208080; Data preliminary, not for publication
Madigan Army Medical CenterMadigan Army Medical Center--Ft. LewisFt. Lewis(Reger et al)(Reger et al)
Non-Random Comparison with Standard of Care
30
20
0
10
Treatment Completers
40
50
60
70
80
90
100
110
PreTre
atment
PostTreatm
ent
Post Tx Follo
w
Up
CA
PS S
core
-Sy
mpt
om S
ever
ity
4 Sessions
Assessment over Time
In: Gerar
di, Roth
baum,
Heekin, R
essler & Rizz
o,
(2008)
. Jou
rnal of
Traumati
c
Stress
. 21(2
), 209-
213.
Emory University (Rothbaum et al)Emory University (Rothbaum et al)Clinician Administered PTSD Scale (CAPS)
PreTreatment, PostTreatment & 3 Month Follow-up
to NIGHTLINE_PTSD_1Mbps.
November 13, 2007 “Coming Home”
November 14, 2006 “Iraq War Veteran Stories”
Recent News Media ReportsRecent News Media Reports
Recent News Media ReportsRecent News Media Reports
November 13, 2007 “Coming Home”
Challenge for Military Healthcare (again from Hoge et al. 2004)
Among Iraq War veterans: “…those whose responses were positive for a mental disorder, only 23 to 40 percent sought mental health care. Those whose responses were positive for a mental disorder were twice as likely as those whose responses were negative to report concern about possible stigmatization and other barriers to seeking mental health care.” (p. 13).
Reconceptualize TherapyVRVR Post Deployment Post Deployment
Reset TrainingReset TrainingOption:
May appeal to a generation of
soldiers who have grown up Digital!
Challenge for Military Healthcare
Reconceptualize TherapyVRVR PostPost--Deployment Deployment
ReintegrationReintegrationTrainingTraining
Option:
May appeal to a generation of
soldiers who have grown up Digital!
Challenge for Military Healthcare
Integrate VR combat exposure as part of a comprehensive program administered upon return from a tour of duty
Since past research is suggestive of differential patterns of physiological reactivity in soldiers with PTSD when exposed to combat-related stimuli (Laor et al., 1998, Keane et al., 1998)
Use initial reintegration procedure that applies our VR PTSD application with physiological recording could be of value
If indicators of such physiological reactivity are present during an initial VR exposure, a referral for continued “Reintegration training” could be negotiated and/or prescribed
This could provide a format whereby the perceived stigma of seeking help/treatment could be lessened as the soldier would be simply participating in post-combat reintegration “training” in
similar fashion to other designated duties to which they are assigned.
Challenge for Military Healthcare
Reconceptualize TherapyVRVR PostPost--Deployment Deployment
ReintegrationReintegrationTrainingTraining
Option:
Clinical/Research Test SitesClinical/Research Test Sites
Fort Lewis, Washington
US Air Force (8 Bases)
Ft. Sill
Weill Medical College of Cornell Emory University
Atlanta VA Hospital
Providence VA/Brown U.
Camp Pendleton
Naval Medical Center San Diego
Walter Reed Army Medical Center
Funded by:Funded by:
Funded by:Funded by: NIH, TATRC, VA, DOD, EU, US Air ForceNIH, TATRC, VA, DOD, EU, US Air Force::
Little Rock VA Hospital Manhattan VA Montrose VA
White River Jct. VA
University of Reading, UK
University of Esbjerg, Denmark
Babes-Bolyai University,Romania
And 12 more coming online And 12 more coming online this month!this month!
Current Research ActivitiesCurrent Research Activities
Two Special Projects WTC 911 Project w/Difede et al. D-Cycloserine Study w/Rothbaum & Davis
Virtual Reality Exposure and D-cycloserine for Treating PTSD in Combat Veterans Rothbaum/Davis, Ph.D. Emory University
Virtual Reality Exposure Therapy for the treatment of PTSD in reservists JoAnn Difede, Ph.D. New York Presbyterian Hospital
The Neuroscience of PTSDThe Neuroscience of PTSD
Developing Novel Diagnostic and Treatment Tools for PTSD using Virtual Reality Technology, Cognitive
Neuroimaging, and other Neurobiological Measures
Under review to DOD CoE/CAM:
Rizzo (PI), Damasio, Damasio, Parsons, Lu, Rothbaum, Difede, Reger, Pato, Rubin, Houston & Bechara
Randomized Clinical TrialRandomized Clinical Trial (Reger et al)(Reger et al)
Enhancing Therapy w/DCSEnhancing Therapy w/DCS (Rothbaum/Difede et al)(Rothbaum/Difede et al)
Assessment of PTSD PostAssessment of PTSD Post--deploymentdeployment(Unger/Keller et al)(Unger/Keller et al)
PTSD/TBI TrialPTSD/TBI Trial (Roy et al)(Roy et al)
Neuroscience FactorsNeuroscience Factors ((DamasioDamasio et al)et al)
Stress InoculationStress Inoculation ((LethinLethin et al)et al)
Virtual Afghanistan Project Virtual Afghanistan Project Spherical Video ExplorationSpherical Video Exploration
Current Research ActivitiesCurrent Research Activities
Next Training: January 2009Next Training: January 2009
January 26-27, 2009
cut to RunConvoy.b
Why do this work???
Ethical Responsibility to reduce human suffering
Assessment, Diagnosis, Selection and StressStressInoculation applications could prevent or lower PTSD incidence and produce soldiers better equipped for combat
Healthcare savings via a reduction in long term service connected disability
As of As of JanuaryJanuary, 2005 , 2005 -- 13,75213,752 Gulf War Vets receiving VA Benefits for PTSDGulf War Vets receiving VA Benefits for PTSD
As of As of SeptemberSeptember, 2005 , 2005 -- 19,35619,356 Gulf War Vets receiving VA Benefits for PTSDGulf War Vets receiving VA Benefits for PTSD
Available at: www.NewYorker.com
A Psychologist’s DREAM!?The capacity to design a functional environment,
precisely administer stimuli, and measure, treat and train performance within the environment.
A Copy of this talk will be available for the attendees. Please cite the source if you
use any of the materials from this talk.
Contact Information:
Albert “Skip” Rizzo, Ph.D.University of Southern CaliforniaInstitute for Creative Technologies Dept. of Psychiatry and School of Gerontology Los Angeles, Californiaarizzo@usc.edu213-740-9819
Thanks!Thanks!
Virtual Reality Cognitive Virtual Reality Cognitive Performance Assessment Test Performance Assessment Test
VRCPATVRCPAT
Dr. Thomas ParsonsDr. Thomas Parsons
The End (for now)
"It would be strange, and embarrassing, if clinical psychologists, supposedly sophisticated methodologically and quantitatively trained, were to lag behind internal medicine, investment analysis, and factory operations control in accepting the computer revolution."
Paul Meehl, 1987
The End (for now)
"It would be strange, and embarrassing, if clinical psychologists, supposedly sophisticated methodologically and quantitatively trained, were to lag behind internal medicine, investment analysis, and factory operations control in accepting the computer revolution."
- Paul Meehl, 1987
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